Misuse of benzodiazepines and Z-drugs in the UK

Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, William Harvey Research Institute, Centre for Clinical Pharmacology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London and Barts Hypertension Clinic, Barts Health NHS Trust, London UK

Benzodiazepines and Z-drugs are commonly prescribed for insomnia and anxiety syndromes and there is increasing concern regarding their misuse. Using an internet-based questionnaire we found that of 1500 respondents 7.7% (n = 116) had misused one or more of these medications. Almost 15% of those misusing at least one of these drugs did so once weekly or more often. The main reasons reported for their use were to help sleep (66.4%), to cope with stress (37.1%) and/or to get high (31.0%). A total of 31% obtained the medications from multiple sources; healthcare professionals (55.2%) and friends/family (39.7%) most commonly. Our study can be used to inform prevention measures for their misuse.

Misuse of benzodiazepines and Z-drugs in the UK

Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, William Harvey Research Institute, Centre for Clinical Pharmacology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London and Barts Hypertension Clinic, Barts Health NHS Trust, London UK

eLetters

We read with interest the results of Kapil et al's survey of the prevalence of benzodiazepines and Z drugs use in the UK. Ever since theirintroduction in the second half of the last century Benzodiazepines have quickly become an important tool in medical practice across a wide spectrum of neurological, psychiatric and related disorders1Kapil et all's article provides valuable information on the prevalence of these drugs in a community sample in the United Kingdom and allows for an updated debate on the appropriate attitude towards them from a clinical and public health perspective. The premise of the article is that these drugs are potentially addictive and a health hazard, which is beyond doubt. Yet, their potential for abuse and dependence seems to have not significantly dented the reliance of many clinicians on them, given their rapid onset of action and their relative tolerability. Between 1979 and 1990 the use of Anxiolytic Benzodiazepines in the US decreased from 11.3% to 8.3% 1. Today these drugs are still widely in use, as highlighted by a number of international studies. The 12-months prevalence of Benzodiazepine use in a large community sample (N=21,425) in six European countries, not including the UK, was 9.17%2. A later survey carried out inSingapore also used the same relevant section of the validated CIDI-3.0 questionnaire. Among 6.616 individuals interviewed only 1.2% had used a Benzodiazepine in the previous year3, possibly reflecting cultural or clinical factors. A very recent US Study reviewing prescribing of Benzodiazepine estimates its prevalence in 2008 among the adult populationat 5.2%4. This might be an underestimate given that non-prescription supply sources were not accounted for. In this context the term 'misuse' that reportedly applies to 29.6% of lifetime Benzodiazepine users in Kapil's survey is broad and misleading. The pattern reported is often clinically negligible (less than once a month) and could reflect difficulties in accessing prompt medical advice for occasional insomnia, anxiety or related conditions where these drugs are actually indicated. A much smaller number had been interested in theirrecreational effects, in line with true substance abuse criteria.It is our impression that Benzodiazepines are burdened with a disproportionate stigma that undermines their clinical relevance in the absence of convincing signs for a growing global epidemic of abuse. Thereis early evidence that this stigma is starting to extend to other GABA-agonists, such as Pregabalin and Gabapentin5. As with many psychotropic medications, when used appropriately and under adequate medical supervision Benzodiazepines are often unavoidable in acute phases of certain illnesses and in the maintenance of others. There is also no indication that they will suffer the fate of Barbiturates any soon in all but disappearing from clinical practice, reinforcing the importance of accurately weighing their negative social and medical impact against theirestablished benefits.?References :1 WHO. program on substance abuse. World Health Organization; 1996 p. 1-5

We agree with Rafael Euba's response to the short report by Kapil et al. which claimed that 7.7% of their sample had 'misused' benzodiazepines and Z drugs, when in fact these drugs were being taken for valid clinical reasons such as sleep disturbance or stress related symptoms. Labelling these people as 'misusers' may explain why only 55.2% obtained their medication from appropriate prescribing sources. Strict guidelines on benzodiazepine prescription may also prevent those with sleep and associated anxiety conditions, which are already under-diagnosed and under-treated (Kasper, 2006; Saddichha, 2010), from being adequately treated. Therefore, an alternative view to established dogma would be that benzodiazepines and Z drugs should be more freely available, so that thosewith anxiety and sleep problems could obtain better symptomatic relief viaestablished, medically approved sources.

Furthermore, in our sample of 40 patients who complained of benzodiazepine dependency (as part of the benzodiazepine litigation back in the 1990s), it transpired that approximately 67% of individuals experienced residual symptoms after overcoming withdrawal from benzodiazepines, as the underlying anxiety condition re-emerged. Again, this challenges the notion that that use of benzodiazepines, particularly in the long-term, should be severely discouraged.

Conflict of interest:
Dr. Hallstrom was extensively involved in the benzodiazepine litigation 25 years ago and received fees from solicitors to examine their clients and to provide reports. There has been no conflict of interest in the last 15 years nor is there one currently.

The short report by Kapil et al. on the misuse of benzodiazepines andZ-drugs in the UK is very interesting, but I find the word "misuse" inappropriate in this context. The authors seem to understand that these drugs are "misused" if they are consumed without "appropriate direction", even when they are taken for insomnia or anxiety, which are in fact their main indications. In these circumstances, the drugs are being "used" for their stated purpose. It seems likely in fact that many of those who take benzodiazepines and Z-drugs without medical direction have perfectly legitimate psychiatric needs, which are not being met by GPs and psychiatrists over-concerned with the potential addictive effects of anxiolytics and hypnotics. The fact that the numbers are so high highlights a significant epidemiological problem.

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